The Antidote

The epidemic of overdoses from pills and heroin has hit Staten Island harder than anyplace else in New York City.Credit Illustration by Chad Hagen

Joseph D’Agosto, a paramedic with the Fire Department’s 23rd E.M.S. Battalion, on Staten Island, is the best person in New York City. During his twenty-four years on the job, he has saved many lives—“hundreds, probably,” he says. D’Agosto is known throughout the department as an instructor in emergency medical techniques. When I went looking for him the other day at battalion headquarters, near the southern end of the island, one of his colleagues said he was out, called him on the phone, and told me an address where I could find him. Somehow I had the impression that D’Agosto would be conducting an instructional session, but he turned out to be getting a tattoo of an owl (“for wisdom”) on his left forearm at Contemporary Tattoo and Gallery, occasional workplace of his friend and E.M.S. colleague Josh Fitch, who was washing down D’Agosto’s arm for stencilling when I came in.

Most Staten Island enterprises are as their signs describe them. Occasionally, one or two storefronts that look no different from the rest also do a steady, word-of-mouth business in the illegal sale of OxyContin, oxycodone, Percocet, and other prescription painkillers. A neighborhood ice-cream truck playing its jingle might also be selling pills, according to police, who keep an eye on ice-cream trucks. A window-blinds and drapery store sold oxycodone pills until the N.Y.P.D. arrested one of the owners and the store closed. At a barbershop called Beyond Styles, on Giffords Lane, in the Great Kills neighborhood, police arrested the owner and two accomplices in October of 2013 for selling oxycodone and other drugs—two thousand pills a week, according to the Drug Enforcement Administration.

The silent sniper fire of overdoses from pills and heroin that has been picking people off one at a time in increasing numbers all over the country for almost twenty years has hit Staten Island harder than anyplace else in the city. For a number of reasons, this borough of four hundred and seventy thousand-plus people offers unusually good entry routes for the opioid epidemic. In 2012, thirty-six people on Staten Island overdosed on heroin and thirty-seven on prescription opioid pills, for an average of almost exactly one overdose death every five days. Many of the dead have been young people in their late teens to early thirties. In this self-contained place, everybody seems to know everybody, and the grief as the deaths accumulate has been frantic and terrified.

I wanted to talk to Joseph D’Agosto because he had recently appeared in the Staten Island Advance for saving an overdose victim. That alone would not have got him in the news, because he saves overdose victims with some frequency. What made this rescue different was that he used a nasal-spray syringe of a drug known as Narcan, whose name comes from the first syllables of “narcotic antagonist,” a term for opioids that reverse the action of other opioids. In Narcan, the antagonist drug is an opioid called naloxone. Like heroin, naloxone is highly soluble in the blood, and it acts almost instantly, reversing the effects of heroin or pain-relief opioid pills often in one or two minutes. Formerly, D’Agosto and other paramedics administered an intravenous dosage of naloxone to revive overdose victims; general use of the nasal-spray injector is something new.

“Same thing every September. He begins to doubt the existence of man, then football season begins, and he snaps out of it.”

Josh Fitch traced the outline of the owl tattoo on D’Agosto’s arm, which D’Agosto extended as if getting an I.V. himself. “We received a call for an unresponsive person in the courtyard of an apartment building, early morning, around three or four o’clock, on a night shift last February,” D’Agosto told me. “The unresponsive person, a lady in her sixties, was slumped over on a bench, in like a robe or a housecoat. Near her we found a pill bottle for painkillers, almost empty, and I saw on the label that it had been filled only a week before. She was not breathing, lips blue, pupils miotic—pinpoint-size—all symptoms of opioid O.D. We put her head back, secured a breathing passage. I took the Narcan injector and sprayed a milligram of the naloxone solution in each nostril, and about a minute later she coughed and started breathing again. My partner that night, Henry Cordero, and I were, like, ‘O.K.! We figured it out!’ We put her on the stretcher and brought her to the hospital, and they took over from there.

“In the past, when we used the naloxone with the I.V., that worked, too, of course. But finding a vein for the I.V. can be difficult. Maybe the person was an I.V. drug user and he’s got collapsed veins in his arms. Maybe you’re in a dim hallway, family members around you crying and screaming—there it’s not as easy finding a vein as in a well-lit hospital room. Also, you have the problem of when they come to, sometimes they get agitated and want to fight you, and with the I.V. there can be a danger of a needle stick from someone who may have a disease. With the Narcan atomizer, none of that is a problem, and anybody can use it. You don’t need a special skill—you just spray it in the nose. And everybody’s got a nose.”

The Narcan nasal-spray program began in Staten Island’s 120th Precinct in January. All first responders—police and firefighters, along with the E.M.T.s—received Narcan syringes and instruction on how to use them. Including the police was important, because they usually get to the scene first, and speed counts; when an overdose victim stops breathing, brain damage begins in four to six minutes and death soon follows. By March, responders with Narcan had saved three overdose victims in the precinct. City higher-ups decided to extend the program to the rest of the borough and, soon afterward, to the rest of the city. More Narcan-produced rescues followed. In June, Governor Andrew Cuomo announced that the Narcan kits would be given to every first-responder unit in the state.

It used to be that the medical profession undertreated pain. Doctors didn’t want to create opioid addicts, and the consensus was that patients should suffer rather than risk addiction. That started to change in the seventies, with the rise of the pain-management movement, when pain came to be seen not only as a symptom but as an illness in itself. Now the worry was of “opiophobia.” A widely used pharmaceuticals textbook advised, “Although many physicians are concerned about ‘creating addicts,’ very few individuals begin their drug addiction problems by misuse of prescription drugs. . . . Fear of producing such medical addicts results in needless suffering among patients with pain.”

Strong opioids like morphine or oxycodone already existed for patients with intense, short-term pain from healing trauma or end-of-life illnesses. Long-term, chronic pain was another matter—no existing drug was ideal for that. Seeing the need, Purdue Frederick, a pharmaceutical company in Norwalk, Connecticut, developed a long-term pain reliever called MS Contin, which was a morphine pill with a time-release formula. When the patent ran out on MS Contin, Purdue introduced a time-release oxycodone pill, OxyContin.

The pill entered the market in 1996 and quickly became an iatrogenic disaster. OxyContin’s purpose was merciful—to provide pain relief at a steady rate over a ten- or twelve-hour period, so a pain sufferer could sleep—and millions benefitted from taking it. But for its effect to last that long the pill had to contain a lot of oxycodone. People discovered that the capsules could be crushed, then swallowed, snorted, or injected for a powerful high. Purdue marketed the drug aggressively to general practitioners who accepted the company’s claim (untested and untrue) that OxyContin was difficult to abuse. Overdoses involving OxyContin soon became horribly routine in places like Maine and West Virginia. As the epidemic of “Oxy” addiction and overdose spread, Purdue did not take the drug off the market. Several states and many individuals sued the company, which fought with tobacco-company-like determination but eventually gave in. In 2007, Purdue pleaded guilty in federal court to misbranding the drug by not stating its potential for causing addiction—a felony—and paid a fine that totalled $634.5 million. It also introduced a version of OxyContin that was more tamper-proof. By that time, the drug had made the company many billions of dollars.

Even with the fines and the deaths, OxyContin showed the profitability of long-term opioid pain relievers and contributed to the enormous proliferation of pain pills nationwide. Therein lay the beginning of Staten Island’s opioid problem. More Staten Islanders work in health care than in any other industry. Health-care workers often know about and have access to pills, and their insurance generally pays for them. Many other Staten Islanders are police officers, firefighters, and sanitation workers, with health insurance from the city. If they get injured on the job, they see their own doctors, who can write prescriptions. Staten Islanders receive the pills, in short, because they are prescribed them and can afford them. In 2012, doctors and hospitals on Staten Island prescribed painkillers at a rate about twice that of the rest of the city.

Kids who abuse pills usually get them first from friends or the family medicine cabinet, but then they have to buy them. Illegal pills sell for as much as forty or fifty dollars apiece. Six or eight dollars, however, will buy a packet of heroin, for a high that’s the same or better. Most people who come to heroin get there by way of pills. New York City is the heroin capital of the country; twenty per cent of all the heroin confiscations and arrests nationwide happen here. When I talked to Agent James J. Hunt, the head of the New York Division of the D.E.A., he said that ninety per cent of New York’s heroin originates in South America and Mexico. Poppy fields in Colombia grow the raw opium, labs hidden in the jungle process it, Mexican drug cartels smuggle the heroin through the Caribbean or across the U.S.-Mexico border, and dealers, who are often Dominicans, package it, stamp it with brand names like Breaking Bad or Government Shutdown, and sell it to street dealers. Heroin confiscations at the border have increased from about five hundred and fifty-six kilos in 2008 to about twenty-one hundred kilos in 2012. In New York in 2014, more than two hundred kilos had been seized by July, more than twice as much as during all of 2013.

Agent Hunt’s office chair at his big desk in D.E.A. headquarters in Manhattan is black and high-backed. He wore a black shirt and a muted tie. His blue eyes and his blond, wavy hair parted almost in the middle made his face stand out as if in an Old Master dark-background oil portrait. I asked if the plan to push large quantities of cheap heroin and undersell the illegal pill market had been the idea of a particular person—like El Chapo Guzmán (the Sinaloan cartel leader who went to jail, escaped, and was recently recaptured). Hunt thought a minute and said, “Yes, it probably was his idea, or the idea of four or five cartel leaders like him.

“In Yonkers recently there were some dealers who were mixing heroin with fentanyl, a very dangerous opioid, and selling it on the street,” Hunt went on. “Four people died from using it, and the dealers kept on selling it even after they knew that. Anybody who would sell heroin is evil.”

The opioid epidemic may seem to be a crisis that simply happened, but actual people set it in motion, and other actual people make it worse and keep it going. The cartel leaders and the smugglers and the dealers belong to the second category. In the first category must be included the former management of Purdue Pharma, three of whom pleaded guilty to a non-felony misbranding charge. Purdue Pharma is the huge drug company that grew from Purdue Frederick, whose owners, Dr. Mortimer Sackler and Dr. Raymond Sackler, were not charged in the case. Their older brother and mentor, Dr. Arthur Sackler, known as the founder of modern pharmaceutical advertising, served as the inspiration for the company’s ambitious OxyContin marketing strategy. The Sacklers made many philanthropic gifts and many things are named after them, such as the Sackler Wing, at New York City’s Metropolitan Museum, with its famous Temple of Dendur.

Staten Island’s special misfortune is to exist at a point where somewhat ambiguous but real corporate crime helped to provide a market opportunity for straight-ahead drug-cartel crime. In the years since Purdue Pharma pleaded guilty, the company has tried to make its product safer and to draw more attention to problems of abuse. During the early years of the OxyContin rollout, it has to be said, Purdue ignored the physician’s basic rule, Primum non nocere—“First, do no harm”—with terrible consequences.

Johnathan Charles Crupi is buried in Triangle 63, Lot 66, Grave 3, in Staten Island’s Ocean View Cemetery. He died in March, at the age of twenty-one. A photograph of him—blue eyes, affectionate smile, gold-colored earring in one ear—looks at you from his marker. The grave is still fresh, the dirt reddish, next to a gravel lane that wanders by. Purple and white impatiens, a pot of campanula, and a circle of white stones brighten the plot. The ocean is difficult to see from the cemetery and impossible to hear. The main sounds are birdsong, a lawnmower, and the nearby buzzing of a Weedwacker.

“If I told you where the happy place in my mind is, you’d start showing up there and ruin it.”

Johnathan Crupi’s parents, Barry and Candace Crupi, did not want his obituary in the Advance to say he “died at home”—a newspaper formula sometimes used for overdose victims. The writeup described him as a “wonderful kid until drugs came” and said he died of a heroin overdose.

In May, the Crupis took part in a New York State Senate Joint Task Force Panel Discussion on Heroin and Opioid Addiction at a community center near the middle of the island. The gathering was one of many held by the New York State Legislature to get public comments on the problem at various locations around the state—the Senate held eighteen such forums, the Assembly held three. For this event, the room, a high-ceilinged conference space, seated a hundred and fifty or more, with many standees along the side. Before the proceedings started, a chatty, neighborly cheeriness overlay the nerve-racked, sometimes desperate mood underneath.

All stood for the Pledge of Allegiance. A state senator, the task force’s head, spoke, followed by other senators. Then Brian Hunt, a panelist identified in the program as “Father of deceased Adam Hunt,” stood up. (He and Agent James Hunt are not related.) Brian Hunt’s voice was in a register almost beyond pain. He said that Adam had been in rehab for two months and came home to look for a job. In February, at a Super Bowl party, he took a drink. Soon afterward, someone sold him heroin. He died on March 2nd of acute heroin intoxication. Some of the people he had bought drugs from, as Hunt later learned, lived in the Hunts’ neighborhood, on the next block. Sellers of heroin hide in plain sight and may be friends and neighbors; sellers of heroin should get life in prison, he said.

Candace Crupi spoke next. Her voice was small, quiet, and almost devoid of intonation. She talked about a time when Johnathan was four and she lost him briefly at a Costco. She said what a sweet boy he was. She said no one was ever beyond redemption, because “every angel has a past and every sinner has a future.” She added that the pharmaceutical companies should help pay for drug treatment, because they’re reaping all the profits and suffering none of the sorrow.

Several young men who stood up at the meeting said they were addicts in recovery and praised a rehab program called Dynamite, in Brooklyn. When I called Dynamite’s number, its executive director, Bill Fusco, and associate director, Karen Carlini, offered to show me around. Dynamite is the short name for Dynamic Youth Community, a rehab program with residential facilities in the town of Fallsburg, upstate, and outpatient services and main offices on Coney Island Avenue, in a distant neighborhood of Brooklyn.

Fusco, who co-founded D.Y.C. more than forty years ago, has the heft and the large hands of a blazing-fast softball pitcher, which he is. Karen Carlini, who’s slim and pretty, began as a patient and then a volunteer at the center, in the seventies. D.Y.C. is for young people between the ages of sixteen and twenty-four. The program begins with a year’s residence at Fallsburg and continues with a year of daily outpatient attendance at the Brooklyn center. At the moment, seventy-five members—“They’re not clients or patients, they’re members of the Dynamite family,” Fusco said—were here on outpatient status, with an almost equal number in residence at Fallsburg. Seventy-eight per cent had entered the program because of addiction to heroin.

Fusco and Carlini and another staffer and I sat and talked with a group of members in a circle in a high-windowed top-floor room with easy chairs and couches. Some of the young women got comfortable with their legs folded under them, as the incoming daylight of sobriety set the atmosphere. There was a moment of everybody looking at one another. A lot could go unsaid—how they got here, the nightmares that went before. Every sentence carried a freight of experience and accomplishment. They had built houses at Fallsburg, and gone without cell phones or Internet, and visited the county fair, and attended religious services in the town, and written letters, and hiked to the waterfall on the property, and played softball, and painted the scenery for the graduation ceremony, and sat on the lawn, and, as one young woman said, “learned how to have sober fun again.”

They all said that they had thought pills couldn’t be so bad, because doctors were prescribing them. “I never thought they could create an addict in me,” one said.

Fusco repeated that they had worked hard to get where they are today and they should be proud, because they did the hardest parts themselves. Later, he told me that the program costs about twenty-eight thousand dollars a year per member. Parents pay a portion, on a sliding scale depending on income, and New York State picks up most of the rest. “I think the taxpayers are justified in expecting that the state will contribute when their kids need this kind of help and the health insurance won’t cover it,” he said.

“Up to now, insurance has allowed for only seven or ten days of rehab, twenty-eight days at most,” Carlini said. “That might work for adults who have families to support and a limited amount of time. But for kids who are addicted rehab takes years, not weeks. The good news is that kids are more resilient than older people. They can recover fully, both physically and mentally.”

Some of the Dynamite members said that at one time or another they had overdosed and naloxone had revived them. To a few this had happened more than once. Though the drug may have saved their lives, none said they enjoyed the experience. Naloxone is like the bouncer of the opioids; it stops the high of heroin or morphine or opioid pills so fast that the user does a hundred-and-eighty-degree return to reality and undergoes the familiar miseries of detoxing in a sudden, intense onset. The reversal is of short duration, though, and after thirty to ninety minutes the person usually slips back into a milder opioid sleep. If the original opioid was in the system in such an amount as still to be a threat, the naloxone must be used again. Most overdoses involve multiple drugs; naloxone works only on other opioids. Alcohol, cocaine, and benzodiazepines like Valium are unaffected by it.

With a minor asterisk, one can say that naloxone was invented in Queens. (A Japanese pharmaceutical company received an earlier patent for the drug, but seems not to have known what it had.) Dr. Jack Fishman, a young biochemist with a Ph.D. from Wayne State University, first developed it in a small lab under the elevated tracks on Jamaica Avenue in the late nineteen-fifties. Ever since morphine was synthesized from opium, in 1803, chemists had been searching for a drug with morphine’s good qualities but none of its bad. Mostly what they’d come up with was other addictive drugs—heroin, for example, invented by an English chemist in 1874 and developed commercially by Germany’s Bayer Company as a cough suppressant aimed mainly at patients with pneumonia and terminal TB. Opioids with antagonistic properties had been discovered before naloxone, but they presented serious problems. Nalorphine and cyclazocine both reversed the effects of pain-relieving opioids but also caused severe dysphoria (the opposite of euphoria), hallucinations, and psychotic episodes.

Dr. Fishman worked at the Sloan Kettering Institute for Cancer Research and had taken a second job at the private lab in Queens because he was going through a divorce and needed the money. Dr. Mozes Lewenstein, the head of narcotics research at a company called Endo Laboratories, oversaw the private lab. A colleague of his at Endo, Dr. Harold Blumberg, proposed that a change in the structure of oxymorphone, a recently synthesized morphine derivative ten times as strong as morphine, might produce an opioid antagonist of comparable potency. Following Blumberg’s idea, Fishman began to work with oxymorphone and, by replacing an N-methyl group in its structure with an allyl group, synthesized naloxone. Tests showed it to be more potent at reversing the effects of opioids than any antagonist synthesized so far. In 1961, Lewenstein and Fishman applied for a U.S. patent for naloxone, called only by its chemical name, N-allyl-14-hydroxydihydro-nor-morphinone. Five years later, they received patent 3,254,088.

The drug turned out to have all kinds of uses. First, as an opioid antidote, naloxone comes with almost no contraindications—it does not combine to bad effect with other drugs. Its serious side effects are rare and few. (A study found that in 1.3 per cent of cases where naloxone was administered, seizures and pulmonary edema occurred.) Though naloxone displaces other opioids, no other opioids displace it. During the period before it wears off, it has the final word. It produces no analgesic effects and is itself non-addictive.

“Before we cut the cake, I want to thank my bride for bringing our wedding in under budget.”

Naloxone’s invention led to important discoveries about the chemistry of the brain and the nervous system, such as the discovery of endorphins. These endogenous opioid peptides—chemicals in the body that provide pain relief and pleasure like pain-relieving opioids—revealed hints of their existence when it was found that electronically stimulated pain relief could be reversed by naloxone. If naloxone could reverse pain relief when no drugs were present, researchers guessed that the body must have its own pain-relief systems. “Endorphin,” the word, comes from “endogenous morphine.” A number of such natural chemicals were later found, along with receptors in the brain upon which they and the opioids acted. Other studies showed that naloxone may block the pain-relieving effects of acupuncture and placebos, temporarily suppress the urge to eat, and reduce the body’s shock and stress reactions.

The drug must be injected or administered intranasally, because it’s not absorbed well by digestion. This is fortunate for drugmakers who want to put safety brakes on drugs meant to be taken only orally. Suboxone, a methadone-like drug used in the treatment of addiction, consists of naloxone combined with an analgesic opioid called buprenorphine. The Suboxone pill releases its buprenorphine under the tongue, but if you try to grind up the pill and inject it for a stronger rush naloxone’s usual downer effect kicks in.

Naloxone is given to newborns whose mothers have had opioid painkillers during childbirth, so the opioid won’t suppress the babies’ breathing. Postoperative patients sometimes are brought out of anesthetic with naloxone. Patients suffering from dissociative disorder, which often causes everything around them to seem unreal, can be treated with naloxone; the drug’s true affinity seems to be with reality. Naloxone has no dysphoric or psychotomimetic effects and no obvious potential for abuse. Anybody can use it to revive an overdose victim with little fear of causing injury. Thebaine, the Tasmania-grown, opium-derived raw-material precursor of oxycodone and other legal opioids, is also the precursor of naloxone; the harmless drug comes from the same stuff as the dangerous ones for which it is the antidote. If there ever was a primum non nocere drug, naloxone is it.

Our Lady Star of the Sea, a Catholic church serving forty-one hundred families, occupies a rise above Amboy Road, in the Huguenot neighborhood. Weekly, the church offers fourteen Masses and a dozen twelve-step-program meetings—seven of Alcoholics Anonymous, two of Pills Anonymous, and one each of Gamblers Anonymous, Adult Children of Alcoholics, and Al-Anon. Cars come and go in the ample parking lot all day. Some guys were leaving an A.A. meeting at the rectory and having an earnest conversation as I went in one afternoon to see Monsignor Jeffrey P. Conway, at that time Our Lady Star of the Sea’s pastor (he has since moved to St. Patrick’s, in nearby Richmondtown). Conway is a tall, narrow-faced, soft-spoken, cerebral man who even in civilian clothes looks set apart. The blue polo shirt, blue slacks, and blue sneakers he was wearing somehow evoked monastic garb.

He had been pastor at this church since 1993 and had watched the opioid problem grow in the area, he said. As an A.A. member himself for thirty-five years—in a kind of apostolic succession from one of A.A.’s founders, Bob Smith, whose nephew was the doctor at a rehab clinic for priests that he attended in Michigan—Conway instituted the church’s various addiction programs. In 2010, two young brothers said they wanted to start a chapter of Pills Anonymous here. Only about five people came to the first meetings, but fifty or sixty attend regularly now.

An assistant brought him a black-bound ledger with “Deaths” on its front cover in gold Gothic letters, and he began to turn its pages slowly. “I wanted to look at this. I’ve presided at a lot of funerals for overdose victims,” he said. “Here’s one . . . March 9, 2011. . . . He was eighteen years old. . . . Another, April 10, 2011 . . . twenty-two years old. I remember he joined A.A. as a sixteen-year-old, and later stopped coming to meetings. I heard he was doing pills and I tried to get in touch with him but he wouldn’t take my calls. . . . May of 2012 . . . He was thirty-one. His family said it wasn’t drugs, but I’m not sure of it. . . . It’s hard to know what to say in your funeral homily, almost impossible to give consolation. The families feel guilty, bereaved, angry at the kid, angry at themselves. . . . Here’s a fifteen-year-old boy. . . . A young woman, May of ’13 . . . And here, June of ’13 . . .This young man was in rehab in Georgia and got out and was found dead a few days later in a motel room. . . . Another, November 13th, end of last year . . . twenty-three years old.”

He laid the book aside. I asked if Scripture has any verses that apply to this situation. “Second Corinthians, Chapter 12,” he said, and then he recited, “ ‘In order that I might not become conceited by the abundance of revelations, a thorn was given me in the flesh, a messenger of Satan, to harass me, to keep me from being too elated. . . . The Lord said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” I will all the more gladly boast of my weaknesses, that the power of Christ may rest upon me. . . . For when I am weak, then I am strong.’

“That’s the twelve-step idea of admitting your weakness in the face of addiction and giving yourself up to a higher power,” he continued. “Alcoholism takes a while to ruin your life, but opioid addiction can happen in a week. It’s almost instant. And the physical addiction of opioids is much harder to fight. Once you’re off the drugs, you still have to maintain your sobriety by going to twelve-step meetings. The programs that get kids off drugs are wonderful, but some don’t emphasize the follow-up enough. At meetings, you have the fellowship of older participants who know about sobriety day to day and year to year. Stopping drugs is the beginning. Then you must keep getting the power in order to stay stopped.”

I wandered all over Staten Island but saw very few outward signs of the opioid crisis. On July 8th, police arrested a pharmacist named Anthony D’Alessandro at his house in a new development for stealing almost two hundred thousand oxycodone pills while he was head of the drug dispensary at Manhattan’s Beth Israel Medical Center (he pleaded not guilty); when I walked through his neighborhood soon afterward, it seemed untouched, with kids playing baseball in a little park and women watering yards. In the pharmacist’s front window was a vase with a bouquet of pussy willows.

I checked behind a high school, where a footpath rumored to be a drug hangout dozed, empty of hangers-out, in the suburban fragrance of newly mown grass. By a shopping-center alley in which drug deals supposedly occur, a young man in a yarmulke was handing out campaign literature to passing shoppers. At a park entrance where, according to police, an undercover cop bought four oxycodone pills for thirty dollars each from a young woman drug dealer, an Uncle Louie G’s Italian Ices truck was playing “I Can’t Stop Loving You,” “The Battle Hymn of the Republic,” and “O Come, All Ye Faithful.”

As I drove by Silver Mount Cemetery, on Victory Boulevard, suddenly a shirtless young man with tousled blond hair and wild eyes was walking toward me in my lane. I veered. His face was weirdly red and he held a clear plastic water bottle in one hand. By the time I pulled over and looked back for him, he was gone.

The plague’s silence and invisibility on Staten Island kept it from public attention for a long while. Deaths from overdose do not tend to happen on the street. As a veteran rehab counsellor said at the Senate Joint Task Force meeting, “The kids would come home by curfew, say good night to their parents, and leave their bedrooms feet first the next morning.” Then commuters started noticing kids nodding out on the ferry and on the Staten Island Railway. Neighbors heard from neighbors about kids who had overdosed, and the bad news spread. Daniel Master, the Chief Assistant District Attorney of Richmond County (Staten Island’s coextensive county), remembers going to a wake for an older person and observing that the other part of the funeral home was filled with weeping teen-agers.

Staten Island is not the healthiest place. It has the highest rate of smoking in the city and shares the highest rate of obesity with the Bronx. More teen-agers here, per capita, use alcohol and binge-drink than in the other boroughs. “Kids drinking is just a part of the culture here,” explained Diane Arneth, the president and C.E.O. of a nonprofit called Community Health Action of Staten Island (CHASI). “Staten Island is a mostly blue-collar community, and drinking on the weekend is a normal way to relax. When kids are around, sometimes they drink, too. The parents say they’d rather have the kids drinking at home than out somewhere on the street. I know people who play drinking games with their underage kids and their kids’ friends at family parties. It’s not seen as a big deal.

“Staten Islanders generally work in other parts of the city, and they have the longest average commuting times in the United States,” Arneth went on. “So the kids are alone a lot. The parents accept that, because this is a supposedly ‘safe’ place. Staten Island kids have cars, they use social media, they’re mobile, looking for the party. Pills fit right into that world. And then, when substance-abuse problems come up that the parents can’t handle, they hate to ask for help. A lot of them are cops, firemen, they’ve done military service. They give help, they’re not used to asking for it. Help is for ‘those people’—families in the projects, Latino immigrants, poor people—not for them. When we went to community boards back in the nineties trying to set up local needle exchanges to stop the spread of AIDS, some of the responses were so cruel. Nobody thought it was their problem. They said, ‘They’re just junkies—let them die.’ Now some of the same people who used to yell at me about why I cared about the junkies are asking for help for their addicted kids.”

Community Health Action of Staten Island works closely with a larger nonprofit called the Staten Island Partnership for Community Wellness, which in 2011 responded to the youth opioid problem by founding a coalition called Tackling Youth Substance Abuse. TYSA’senterprisingdirector, Adrienne Abbate, brought together many groups and agencies to look for solutions, and the idea of giving Narcan kits to all emergency personnel came from one of tysa’s meetings in 2013.

If you want a Narcan kit of your own, Community Health Action of Staten Island will provide you with one at no charge. You have to attend a training session at a CHASI office, where you watch a PowerPoint presentation, hear some facts (drug overdoses recently overtook car accidents as the leading cause of accidental death in the United States; most victims of drug overdose are between the ages of thirty-five and fifty-four), answer questionnaires having to do with your knowledge of opioids, and do a hands-on assembly of syringes from kits that are past their expiration dates. You leave with a small blue nylon zip-up bag that contains a prescription for the drug signed by a doctor or a nurse practitioner, two syringes and two capsules in small cardboard boxes that say “Naloxone Hydrochloride” on them, two “Intranasal Mucosal Atomization Devices” that fit onto the syringes, a pair of rubber gloves, two alcohol wipes, and a mouth-to-mouth-resuscitation face shield.

Joshua Sippen, a vice-president of CHASI, led the session that I attended. Before he began, he pointed me out and said I was a reporter, in case anyone in the group objected on the ground of privacy; a number of the attendees were the mothers of addicts. Nobody did. Afterward, a woman named Melissa Forsyth, who had been sitting a few rows up, introduced herself to me as Missy. I was glad to meet her. She has a good laugh—the kind that’s full-throated and infectious, an intact survival from a younger self. She said her son had been addicted to heroin. Like others there, she wanted the naloxone kit in case she ever had to save her child. Data show that as many as eighty-five per cent of overdose victims are with other people at the time of the overdose; if there’s naloxone in the vicinity and someone to administer it, they could be saved.

A few days later, she and I met at a bagel place on Bay Street. She was on a break from her job as a Y.M.C.A. peer counsellor working with families of addicts, she had a four-month-old girl she was taking care of in a stroller, she was getting lunch for herself and her seventeen-year-old daughter, Leanne, and her phone kept ringing. Missy Forsyth is forty-six years old. Her husband, a New York City firefighter, is forty-seven. Her brown hair was pulled back in a clip, and she wore a patterned top and a pair of rectangular glasses, lightly tinted purple.

“My addict is my oldest son, Joe,” she told me, jiggling the baby on a knee. “He had a horrible experience—his cousin Amanda, who he was close to, was hit by a car and killed on Richmond Avenue coming out of a Sweet Sixteen party in 2006, and he blamed himself. He was supposed to come home and take care of his younger siblings so his father could pick her up. Of course, the accident was not his fault, but he started drinking heavily, then doing pills, and eventually he went to heroin. We understood how bad it was when we found he’d been taking money out of a family member’s bank account.”

She answered a phone call, got a bottle of water for the baby, and told her daughter what sandwich she wanted. “Joe says he’s clean now,” she said. “He’s been in three rehab programs. I hope that’s finally true. But, really, it never ends. He went to college at Oneonta, left after a year. Worked at a café, got a job as an exterminator, went to College of Staten Island, dropped out. Did a year of treatment at a residential rehab, came back, started working at a brand-new hotel in Brooklyn, lost that job. Now he lives with his fiancée. The disease is hard to fight, and he kept getting sucked back in. I support him when he’s in recovery, at arm’s length when he’s not.”

“Kids in college? Well, won’t it be nice to have them home?”May 16, 2005

A young woman she knew came in and stopped to talk to her. (People in Staten Island seem constantly to run into friends and acquaintances when they go out.) “I used to try to control what my kids do, but I’ve stopped that,” she said, turning back to me. “I was a helicopter parent, but my helicopter landed long ago. Now I’m working on a certification in counselling at C.S.I., I volunteer for the Y.M.C.A., and I do presentations at schools about drug addiction. I want to give people a face they can put with the addiction crisis. I was very involved with my kids’ lives, coached their sports teams, drove them to lessons, and still this happened to us. I tell the high-school kids again and again that opioid pills can make them addicts in five days. I say, ‘Don’t drink, but if you do, whatever you do, DO NOT take any pill. Stick to alcohol!’ ” She laughed; she was kidding about the last part.

“Joe is a loose, tall, gangly sort of kid,” she said after a moment, readjusting the baby in her arms. “As a little boy and a teen-ager, he was always kind of flopping around and tripping and falling down, and then he’d get right up again and be fine. It’s a reality I’ve accepted in my life that Joe may one day be dead. But so far he’s still alive. As long as he’s still breathing, I’ve got hope.”

In 2012, New York State passed a law called ISTOP/P.M.P., for Internet System for Tracking Over-Prescribing/Prescription Monitoring Program, and it went into effect in August, 2013. ISTOP requires that most prescribers of painkillers and other drugs with the potential for abuse check the state’s Prescription Monitoring Program to see what the patient’s prescription history has been during the previous six months before giving out a prescription. The idea is to make it difficult for people to go to a series of doctors and get repeats.

Within a few months, evidence seemed to show that ISTOP had reduced the amount of illegal opioids on the market. Critics said the law would create a greater demand for heroin, and that seemed to have occurred. According to N.Y.P.D. Captain Dominick D’Orazio, commanding officer of Staten Island Narcotics, seizures of pills had gone down forty-four per cent, while seizures of heroin had gone up by the same amount. D’Orazio said he saw this as a good sign for the long run, because virtually everybody who tries heroin nowadays begins as an opioid pill abuser; fewer pills out there may mean fewer heroin addicts in the future.

Diane Arneth took a similarly positive view of what sensible laws and public-health policy can accomplish. She noted that AIDS needle-exchange programs, which met resistance not only in Staten Island but all over the country, reduced the number of needle-transmitted AIDS cases in New York from fifty per cent in 1992 to four per cent today. Programs that are now handing out naloxone kits in Chicago and San Francisco and other cities started, like her own CHASI, as providers of AIDS services and needle exchanges. Reducing overdose deaths will be their next victory, she believes.

An August 28th press release from the New York City Department of Health and Mental Hygiene announced that the citywide rates of drug-overdose deaths had gone up forty-one per cent between 2010 and 2013. Now the city’s average for such deaths is two a day. The Staten Island overdose death rate, however, is starting to come down after its fourfold increase between 2005 and 2011. The department said that the aggressive approach to Staten Island’s overdose crisis would now be applied elsewhere in the city.

On Staten Island, the new Narcan program had resulted in thirteen overdose reversals by July, adding to the thousands naloxone has already rescued nationwide. Dr. Jack Fishman could be proud. When he invented naloxone, he was only in his twenties; I wondered if he might still be alive, and what he thought of his invention now. It turned out that he died in December, 2013, but his oldest son, Howard, lives on the Upper West Side. Howard remembered the storefront lab, the El tracks overhead, the smell of chemicals, and the drugstore next door where his father used to buy him a pistachio ice-cream cone after his visits. After his father and his father’s parents escaped from Poland, in the thirties, they were penniless, Howard told me. His father’s pharmaceutical discoveries and career eventually made his fortune. He did important work on breast cancer, headed a pharmaceutical company, served as a consultant to the World Health Organization, and was director of research at the Strang-Cornell Institute for Cancer Research until shortly before his death.

I asked Howard if his father took satisfaction from the fact that his invention had saved so many lives. “He was a complicated man,” Howard said. “Like many super-achievers, he thought he had never really achieved anything. He shied away from the spotlight. He didn’t talk about himself; he talked about other people—like when he met Kissinger, he talked about that. Originally, he had wanted to be a rabbi. He was very generous to his family members around the world. He was a good father. I’m happy just to bask in his glow. His was a well-lived life.”

A woman whom naloxone revived more than a decade ago, when she was in her twenties, now works for a national nonprofit that fights drug addiction and its dysfunctions. She is married, with two small children, and her official, job-related manner is bright and hopeful. When I asked her what being revived by naloxone had felt like, she hesitated. Her voice changed; a particular quiet bleakness filled it. “When I overdosed, I was with some other people, and one of them had a naloxone injector kit he had bought from his dealer,” she said. “I guess this dealer was kind of conscientious, if that doesn’t sound too strange. Maybe he wanted his clients to be safe, so he wouldn’t be hit with drug-induced-homicide charges. Anyway, he sold naloxone kits sometimes. Back then, there were no naloxone distribution programs where we were.

“So we did heroin, and I overdosed, and the guy with the naloxone injected me with it, and all I remember is waking up and feeling so horrible that I thought the people I was with were being mean to me. I didn’t thank anybody for saving me—I was only angry and upset that they had made me feel like this. The withdrawal came on immediately and it was very, very painful, like twenty times worse than the worst flu I ever had. But without the naloxone I don’t know what would have happened. The thought of being left passed out where I was still scares me. We were homeless junkies. Nobody who saw me would have bothered with me. No way anybody would’ve called 911.”

She talked about her recovery and what it still involves. I asked her what she imagined would be the best possible result of the work she’s doing, and she said, “I love that question!” Her voice brightened completely. “We’re going to stop this opioid pandemic!” she said, and began to explain how. ♦